Tips for the patient to adapt to living after gastric surgery

The disease outcome for patients with gastric (stomach) cancer is poor- only 20% of patients survive for five years after receiving their diagnosis. The main reason for this is that the condition often presents late, with symptoms that are not always immediately suggestive of cancer. As a result the cancer is allowed to develop to an advanced stage before patients receive any treatment, which, as with most cancers, results in a poorer disease outcome. Treatment for stomach cancer normally involves anti-cancer medication alone or in combination with surgery. The addition of gastric surgery, where either part or all of the stomach is removed, dramatically improves disease survival compared to treatment with anti-cancer medications alone (22% and less than 10% survival after five years respectively). Unfortunately gastric cancer mainly affects the elderly population, with many patients often not fit for major surgery. In those patients who are suitable, a decision about whether to receive surgery should be made after a discussion with a consultant surgeon.

Surgery itself is associated with a number of complications and, although it generally increases survival, can cause considerable physical injury and psychological distress to patients. This can directly or indirectly have a major impact on patients' quality of life. The complications of gastric surgery can be divided into two main categories: metabolic complications, which affect the biochemical reactions that occur within the body and physical complications, that occur due to the way in which different organs are taken out and the remaining ones stitched back together in gastric surgery. This essay will discuss the various ways in which patients can adapt the way in which they live after having gastric surgery to attempt to reduce these complications.

The most common physical complication of gastric surgery is abdominal fullness. This is defined as the feeling of earlier satiety after meals compared with prior to surgery. It may be associated with abdominal discomfort and bloating and is due to removal of the stomach. In health the functions of the stomach include continuing the process of digesting (breaking down) food and temporarily storing food before it reaches the small intestine. After gastric surgery however removal of part or all of the stomach results in larger pieces of food reaching the small intestines very rapidly, causing a quicker feeling of fullness. If the food is sufficiently large it may stretch the wall of the small intestines and patients may experience abdominal discomfort or pain. To counteract this, patients should slowly consume smaller meals to allow time for food to pass further along the small intestine before eating again. In particular it is high-fibre foods such as wholegrain bread, rice, pasta and oats that cause abdominal fullness. Initially after gastric surgery patients should therefore avoid these foods. Over time high-fibre foods should gradually be re-introduced back into the diet.

A reduction in the amount of food per meal however would result in patients losing weight. This is already a side effect of the anti-cancer medication taken for stomach cancer; therefore it is also important that patients also increase the number of meals consumed each day. Taking small, more frequent meals also helps prevent some of the metabolic complications of gastric surgery. These will be discussed later. Abdominal fullness often improves over time, therefore it is important that patients persist with their modified diet should they experience this complication.

Due to the unpleasant feeling of early satiety and abdominal discomfort experienced in abdominal fullness many patients are unable to sufficiently increase their meal frequency despite eating smaller quantities. As a result calorie intake is reduced resulting in weight loss. This may be exacerbated by loss of the stomach's digestive function. The reduced ability to breakdown food results in less being absorbed from the intestines into the blood. It is therefore important that following gastric surgery patients consume high calorie foods to avoid weight loss.

Another physical complication of gastric surgery for stomach cancer is something called afferent loop syndrome. Such patients presents with green vomit, due to the expulsion of a green substance called bile, and abdominal pain. In health the passage of food from the stomach into the small intestine causes the release of bile, which helps to digest fats and oils. Bile is released from the liver to join food in the small intestine (see figure 1).

Some patients with stomach cancer receive a surgical procedure called a Billroth II. Here the part of the stomach that remains after the operation is attached to a part of the small intestine further along from where bile enters from the liver (see figure 2).

As a result the top part of the small intestine (marked on diagram 2 by a *) can become filled with bile causing abdominal pain. The bile may be expelled out orally causing green vomit. Vomiting is often worse in the morning as bile can build up in the small intestine overnight. Patients suffering from such morning vomiting should take indigestion medication (such as aluminium hydroxide) daily to help avoid this symptom.

The pancreas (shown in yellow in figures 1 and 2) releases potent chemicals that help digest food. They join the bile in the ducts entering the small intestine. Following a Billroth II, if the top part of the small intestine becomes completely blocked by narrowing (which can develop after surgery) or by a blockage of bile then pancreatitis can develop. This is a potentially life threatening condition that requires emergency surgery. Both afferent loop syndrome and pancreatitis can be exacerbated by quickly eating larger meals, reiterating the need to slowly consume small meals after gastric surgery.

The main metabolic complications of gastric surgery are vitamin and mineral deficiencies. The stomach plays an important role absorbing minerals such as iron and calcium and vitamins B12, C and D; therefore the body may receive an insufficient amount of any one of these from diet alone. Vitamin B12 and iron are required to make healthy red blood cells and a lack of these can cause anaemia. This can result in patients becoming tired and breathless. Vitamin C is involved in the normal functioning of the immune system, the body's natural defence to fight off infections. Deficiency in vitamin C can cause increased susceptibility to infection and wounds or burns may take longer to heal. Vitamin D and calcium are important in keeping bones and muscles strong and healthy. A lack of vitamin D or calcium can cause weak bones that are at increased risk of developing small breaks. As a result patients should take oral supplements of iron, calcium and vitamins C and D to prevent deficiencies of these substances as well as monthly vitamin B12 injections.

Dumping syndrome is another important complication of gastric surgery. As aforementioned, removal of the stomach causes rapid transit of food into the small intestine. The stomach is also involved in the breakdown of starchy and sugary foods. After gastric surgery the rapid arrival of particularly starchy or sugary foods can cause water to move from out of the blood into the small intestine. As much as 1.5 litres of water can be lost from the blood causing a sudden drop in blood pressure resulting in faintness, sweating, needing to lie down and an abnormal sensation of ones own heartbeat (palpitations). The extra water in the small intestines can also cause nausea, vomiting, diarrhoea, indigestion and bloating. As a result, following gastric surgery, patients should rest for 25-45 minutes after each meal eat slowly and avoid highly sugary foods (such as cakes, chocolates sweets).2 Patients should also slowly add fibre back into their diet, avoid fluid foods such as soup and eat small, frequent meals.

Highly sugary foods can also cause late dumping. As well as causing water to be removed from blood, the rapid arrival of highly sugary foods to the small intestine causes a quick increase in blood sugar levels. The body responds by pumping out large volumes of a hormone called insulin to try and reduce the blood sugar levels.

However exceptionally high levels of sugar absorbed into the blood may cause the body to release surplus insulin. As a result, one to three hours after a highly sugary meal patients may experience a rebound abnormally low blood sugar level. This can cause headaches, sickness, sweating and if severe even coma, seizures or death. This reiterates the importance for patients to avoid highly sugary meals. In addition following gastric surgery patients should eat meals of guar (which can be added to baked goods, meats, dairy products and condiments) and pectin (found in peaches, apples, oranges and apricots) that help to reduce the rate at which sugar is absorbed into the blood, dampening the body's release of insulin. Patients suffering from late dumping might also be prescribed a medication called Acarbose, which helps to reduce the amount of insulin produced by the body. Both dumping syndrome and late dumping improve over time.

Due to having to make significant lifestyles alterations and worrying about the various complications of gastric surgery many patients may start to find it difficult to cope after gastric surgery. If patients start to lose hope it may be helpful to join patient support groups for help and advice from others who are experiencing similar problems. In addition other support is available to patients after gastric surgery for example from GPs, dieticians, physiotherapists and occupational therapists.

Therefore, the most important adaptation that patients should make to their lives is to consume small amounts of food slowly to avoid abdominal fullness and dumping syndrome. More frequent meals should be introduced to avoid weight loss and the importance of a balanced diet is especially important following gastric surgery as meals heavy in sugar or starch also cause dumping syndrome. Patients should remember to take daily supplementary vitamins and minerals and consume meals containing guar and pectin to avoid late dumping. In particular it is important that patients persist with their new dietary regimes after gastric surgery, as both the physical and metabolic complications reduce over time.